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بسم هللا الرحمن الرحيم Lecture Title: Acute Pain Management Lecturer name: Lecture date: Lecture Objectives.. Students at the end of the lecture will be able to: 1. 2. 3. 4. 5. 6. Learn a common approach to emergency medical problems encountered in the postoperative period. Study post-operative respiratory and hemodynamic problems and understand how to manage these problems. Learn about the predisposing factors, differential diagnosis and management of PONV. Understand the causes and treatments of post-operative agitation and delirium. Learn about the causes of delayed emergence and know how to deal with this problem. Learn about different approaches of post-Operative pain management Postoperative care Post Anesthesia Care Unit “PACU” PACU • Design should match function • Location: – Close to the OR. – Access to x-ray, blood bank & clinical labs. • Monitoring equipment • Emergency equipment • Personnel Admission to PACU Steps: • Coordinate prior to arrival, • Assess airway, • Administer oxygen, • Apply monitors, • Obtain vital signs, • Receive report from anesthesia personnel. PACU - ASA Standards 1. Standard I All patients should receive appropriate care 2. Standard II All patients will be accompanied by one of anesthesia team 3. Standard III The patient will be reevaluated & report given to the nurse 4. Standard IV The patient shall be continually monitored in the PACU 5. Standard V A physician will signing for the patient out of the PACU Patient Care in the PACU • Admission – Apply oxygen and monitor – Receive report • Monitor & Observe & Manage To Achieve • Cardiovascular stability • Respiratory stability • Pain control • Discharge from PACU Monitoring in the PACU • Baseline vital signs. • Respiration – RR/min, Rythm – Pulse oximetry • Circulation – PR/min & Blood pressure – ECG • Level of consciousness • Pain scores Initial Assessment 1. Color 2. Respiration 3. Circulation 4. Consciousness 5. Activity Aldrete Score Score 2 Activity Respiration Circulation Consciousness Oxygen Saturation Moves all extremities Breaths deeply and coughs BP + 20 mm of preanesth. level Fully awake Spo2 > 92% BP + 20-50 mm of preanesth. level Arousable on calling With suppl. O2 Not responding Spo2 <92% freely. 1 Moves 2 extremities Dyspneic, or shallow breathing on room air Spo2 >90% BP + 50 0 Unable to move Apneic mm of preanesth. level With suppl. O2 Common PACU Problems • Airway obstruction • Bleeding • Hypoxemia • Agitation • Hypoventilation • Delayed recovery • Hypotension • “PONV” • Hypertension • Pain • Cardiac dysrhythmias • Oliguria • Hypothermia 1. Airway Obstruction • Most common: tongue fall back posterior pharynx • May be foreign body • Inadequate relaxant reversal • Residual anesthesia Management of Airway Obstruction • Patient’s stimulation, • Suction, • Oral Airway, • Nasal Airway, • Others: – Tracheal intubation – Cricothyroidotomy – Tracheotomy 2. Hypoventilation • Residual anesthesia – Narcotics – Inhalation agent – Muscle Relaxant • Post oper - Analgesia – Intravenous – Epidural Treatment of Hypoventilation • Close observation, • Assess the problem, • Treatment of the cause: – Reverse (or Antidote): • Muscle relaxant Neostigmine • Opioids Naloxone • Midazolam Anexate 3. Hypertension • Common causes: e.g. – Pain – Full Bladder • Hypertensive patients • Fluid overload • Excessive use of vasopressors Treatment of Hypertension • Effective pain control • Sedation • Anti-hypertensives: – Beta blockers – Alpha blockers – Hydralazine (Apresoline) – Calcium channel blockers 4. Hypotension • Decreased venous return – Hypovolemia, • fluid intake • losses • Bleeding – Sympathectomy, – 3rd space loss, – Left ventricular dysfunction Treatment of Hypotension • Initially treat with fluid bolus, • + Vasopressors, • + Correction of the cause 5. Dysrhythmias • Secondary to – Hypoxemia – Hypercarbia – Hypothermia – Acidosis – Catecholamines – Electrolyte abnormalities. Treatment of Dysrhythmia • Identify and treat the cause, • Assure oxygenation, • Pharmacological 6. Urine Output • Oliguria – Hypovolemia, – Surgical trauma, – Impaired renal function, – Mechanical blocking of catheter. • Treatment: – Assess catheter patency – Fluid bolus – Diuretics e.g. Lasix 7. Post op Bleeding Causes: • Usually Surgical Problem, • Coagulopathy, • Drug induced Treatment of Post op Bleeding Treatment: • Start i.v. lines push fluids • Blood sample, - CBC, - Cross matching, - Coagulopathy • Notify the surgeon, • Correction of the cause 8. Hypothermia • Most of patients will arrive cold • Treatment: – Get baseline temperature – Actively rewarm – Administer oxygen if shivering – Take care for: • Pediatric, • Geriatric. 9. Altered Mental Status • Reaction to drugs? – Drugs e.g. sedatives, anticholinergics – Intoxication / Drug abusers • • • • • Pain Full bladder Hypoventilation Low COP CVA Treatment of Altered Mental Status • Reassurances, • Always protect the patient, • Evaluate the cause, • Treatment of symptoms, • Sedatives / Opioids if necessary. 10. Delayed Recovery • Systematic evaluation – Pre-op status – Intraoperative events – Ventilation – Response to Stimulation – Cardiovascular status Delayed Recovery • The most common cause: – Residual anesthesia Consider reversal • Hypothermia, • Metabolic e.g. diabetic coma, • Underlying psychiatric problem • CVA 11. Postoperative Nausea & Vomiting “PONV” • Risk factors – Type & duration of surgery, – Type of anesthesia, – Drugs, – Hormone levels, – Medical problems, – Autonomic involvement. Prevention of PONV • NPO status • Dexamothasone, • Droperidol, • Metoclopramide, • H2 blockers, • Ondansetron, • Acupuncture 12. Postoperative Pain Causes: Incisional Laparoscopy Others: Skin and subcutaneous tissue Insuflation of Co2 Deep cutting, coagulation, trauma Positional nerve compression, traction & bed sore. IV site needle trauma, extravasation, venous irritation Tubes drains, nasogastric tube, ETT Surgical complication of surgery Others cast, dressing too tight, urinary retention PAIN MEASUREMENTS Subjective Uni-Dimensional Multidimentional Objective Behavioral. VRS, VAS & NRS. McGill P Q, Physiological. Facial expression. Pain Inventory. Neuro-endocrinal. Algometry. ACUTE PAIN Chronic Pain Both Pain Scores Visual Analogue Scale (VAS) 0 10 Numeric Rating Scale (NRS) Verbal scale No Pain Mild Moderate Severe Pain Wong-Baker “Faces Scale” ACUTE POSTOPERATIVE MANAGEMENT TOOLS Regional Techniques Pharmaco - Therapy 1. Non Opioid Analgesics 1. Local infiltration NSAADs 2. Wound perfusion 3. Intra-abdominal inj. of LA/Analg. 4. Intercostal & Interpleural 5. Paravertebral 6. USG-RA: e.g. TAP 7. Neuraxial: Analgesic /Antipyretic Analgesic/Anti-inflam/Antipyretic NSAIDs Non-selective COX inhibitors Selective COX-2 inhibitors 2. Opioids Weak Opioids. Strong Opioids. Mixed agonist-antagonists 3. Adjuvants -2 Agonists LA SP inhibitors NMDA inhibitors Anticonvulsant / Antidepressants Calcitonin Relaxants Cannabinoids Others Epidural: Thoracic Lumbar Spinal Single shot CSA CSE WHO IV Interventional WHO Ladder Updated Severe pain (7-10) WHO III Strong opioids ± Adjuvant Moderate pain (4-6) WHO class II Weak opioids ± Adjuvant Mild pain (0-3) WHO class I NSAIDs ± Adjuvant By the mouth By the clock By the ladder 1. Non Opioid Analgesics NSAADs Analgesic / Anti-inflam / Antipyretic / Anticoagulant ASA Analgesic /Antipyretic Paracetamol Severe pain (7-10) WHO III Strong opioids ± Adjuvant NSAIDs Non-selective COX inhibitors: Moderate pain (4-6) WHO class II Weak opioids Diclofenac & Ketoprofen Selective COX-2 inhibitors Celecoxib & Rofecoxib ± Adjuvant Mild pain (0-3) WHO class I NSAIDs ± Adjuvant Scientific Evidence – NON OPIOID ANALGESICS 1. Paracetamol: 1. is an effective analgesic for acute pain; the incidence of adverse effects comparable to placebo (Level I [Cochrane Review]). 2. Paracetamol / NSAIDs given in addition to PCA Opioids Opioid consumption (Level I). 2. NSAIDs: 1. are effective in the treatment of acute postoperative (Level I ). 2. With careful patient selection and monitoring, the incidence of renal impairment is low (Level I [Cochrane Review]). 3. NSAIDs + Paracetamol improve analgesia compared with paracetamol alone (Level I). Acute Pain Management - Scientific Evidence - AAGBI Guidelines 2010 WHO Ladder II - Weak Opioids: 1. Tramadol: – Tramadol : Morphine: • • Parenteral = 1 : 10 & Oral = 1 : 5 Dose: 200 – 400 mg/d Severe pain (7-10) 2. Codeine: – – WHO III Strong opioids ± Adjuvant Metabolized to morphine. Codeine : Morphine = 1 : 10 Moderate pain (4-6) WHO class II Weak opioids 3. Dextro-propoxyphene: – – Methadone Derivative Prolongation of Q-T interval. ± Adjuvant Mild pain (0-3) WHO class I NSAIDs ± Adjuvant Scientific Evidence – WEAK OPIOIDS 1. Tramadol: has a lower risk of respiratory depression & impairs GIT motor function < other opioids (Level II). is an effective treatment for neuropathic pain (Level I [Cochrane Review]). 2. Dextropropoxyphene: has low analgesic efficacy (Level I [Cochrane Review]). Acute Pain Management - Scientific Evidence - AAGBI Guidelines 2010 WHO Ladder III - Strong Opioids 1. Morphine: 1. Sedation 2. PONV 3. Respiratory Depression 2. Fentanyl 1. Rapid action, Short duration. 2. Fentanyl : Mophine = (1:10) Severe pain (7-10) 3. Pethidene: 1. Active metabolite: t½ . 2. Prolongs Q-T interval. 3. Pethidine : Mophine = (1:10) WHO III Strong opioids ± Adjuvant Moderate pain (4-6) WHO class II Weak opioids 4. Hydromorphone: 1. Powerful, rapidly acting. 2. Release is in distal gut. 3. Hydromorphone : Morphine = 1 : 5 ± Adjuvant Mild pain (0-3) WHO class I NSAIDs ± Adjuvant WHO Ladder IV – Regional Anesthetic Techniques 1. 2. 3. 4. 5. 6. 7. 8. Local infiltration Wound perfusion Intra-abdominal LA Intercostal Interpleural Paravertebral USG - RA: e.g. TAP Neuraxial: Epidural: Thoracic Lumbar Spinal Single shot CSA CSE WHO IV Interventional Severe pain (7-10) WHO III Strong opioids ± Adjuvant Moderate pain (4-6) WHO class II Weak opioids ± Adjuvant Mild pain (0-3) WHO class I NSAIDs ± Adjuvant Neuraxial (Spinal / Epidural) (LA / Opioids / others) • Advantages: – Provide prolonged & effective analgesia • Side effects – Respiratory depression. – N/V. – Pruritis. – Urinary retention. WHO Algorithm for Management of Pain + Multidisciplinary: • Adjuvant therapy. WHO III • Psychotherapy. Strong opioids • Physioltherapy. Neuraxial LA Opioids Plexus block • Causal diag. & ttt. Paravertebral / PNB WHO class II Weak opioids Non-pharmacological LA infiltration WHO class I NSAIDs Management Algorithm for Postoperative Pain Diagnosis Procedure Specific Pain manag. Preventive / Preemptive Pain Assessment ttt of Pain and Co morbidities 1ry Treatment Supportive Treatment Pharmacotherapy Psychological ttt. Interventional Physical / Rehab. PACU Discharge Criteria • Fully Awake, • Patent airway, • Good respiratory function, • Stable vital signs, • Patency of tubes, catheters, IV’s • Pain free, • Reassurance of surgical site. Postanesthesia Discharge Scoring System Vital Signs (PR & ABP) Activity PONV Pain Surgical Bleeding 2: Within 20% of preoperative baseline 2: Steady gait, no dizziness 2: Minimal: treat 2: Acceptable with PO meds control per the patient; controlled with PO meds 2: Minimal: no dressing changes required 1: 20-40% of preoperative baseline 1: Requires assistance 1: Moderate: treat with IM medications 1: Not acceptable to the patient; not controlled with PO meds 1: Moderate: up to 2 dressing changes 0: >40% of preoperative baseline 0: Unable to ambulate 0: Continues: repeated treatment 0: Severe Uncontrolled pain 0: Severe: more than 3 dressing changes Reference book and the relevant page numbers.. Thank You Dr. Date: